San Antonio Medicine October 2022

TABLE

DIVERSITY IN MEDICINE

Confidentiality By Neal S. Meritz, MD 12

Diversity in Dermatology: A Need for More Inclusivity

By Tue “Felix” Nguyen, Bahar Momin and Marie Vu 14

“You Have No Idea” One Doctor’s Journey to Address Disparity While Combatting Burnout and Judgement

By Melissa A. Walker, DO 16

Challenges and Opportunities in Increasing the Hispanic Participation in Our Medical Schools

By Ronald Rodriguez, MD 18

Call To Action: UT Health Students Address Need for Accessible Chronic Disease Self-Management Among the San Antonio Refugee Population By Mahima Ginjupalli and Salma Yazji 20 Establishing a Chronic Disease Self-Management Program at San Antonio Refugee Clinic By Mahima Ginjupalli and Salma Yazji 21

Between the Lines: The Origins of Auscultations, A Storytelling Project By Winona Gbedey 24 Perspective on Care for the Transgender Patient Experiences from the PRIDE Clinic By Joshua Carrasco, Louisa Xie and Brent Arcayan 26

BCMS President’s Message

Alliance President’s Message

From the Medical Students: Wound Healing By Winona Gbedey, More Than A Diagnosis By Lauren C. Jameson

From the Medical Students: The Gifts of Orion By Dawson Tan, How I Got Here By Yousef Salem

Word Stories on Kindness By Medical Students

Generations Serving BCMS A Look Back By John M. Smith III, MD

“To See Ourselves” The Works of Dr. Oliver Sacks By David Schulz

Ford Maverick By Stephen Schutz,

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ELECTED OFFICERS

rajeev Suri, Md, President

Brent W. Sanderlin, do, Vice President

Ezequiel “Zeke” Silva iii, Md, Treasurer

Alice Gong, Md, Secretary

John J. nava, Md, President-elect

rodolfo “rudy’ Molina, Md, Immediate Past President

DIRECTORS

vincent Fonseca, Md, MpH, Member

Woodson "Scott" Jones, Md, Member

lubna naeem, Md, Member

lyssa n. ochoa, Md, Member

Jennifer r rushton, Md, Member

raul Santoscoy, do, Member

John Shepherd, Md, Member

Amar Sunkari, Md, Member

lauren tarbox, Member

Col. tim Switaj, Md, Military Representative

Manuel M. Quinones Jr., Md, Board of Ethics Chair

George F. “rick” Evans, General Counsel

Jayesh B. Shah, Md, TMA Board of Trustees

Melody newsom, CEO/Executive Director

taylor Frantz, Alliance Representative

ramon S. Cancino, Md, Medical School Representative

lori Kels, Md, Medical School Representative

ronald rodriguez, Md, phd, Medical School Representative

Carlos Alberto rosende, Md, Medical School Representative

BCMS SENIOR STAFF

Melody newsom, CEO/Executive Director

Monica Jones, Chief Operating Officer

Yvonne nino, Controller

Mary nava, Chief Government Affairs Officer

Brissa vela, Membership Director

phil Hornbeak, Auto Program Director

August trevino, Development Director

Betty Fernandez, BCVI Director

Al ortiz, Chief Information Officer

PUBLICATIONS COMMITTEE

John Joseph Seidenfeld, Md, Chair

Kristy Yvonne Kosub, Md, Member

louis doucette, Consultant

Alan preston, phd, Member

rajam S. ramamurthy, Md, Member

Adam v. ratner, Md, Member david Schulz, Community Member

Faraz Yousefian, do, Member neal Meritz, Md, Member

Jaime pankowsky, Md, Member

Moses Alfaro, Student Member

Winona Gbedey, Student Member tue Felix nguyen, Student Member

Cara J. Schachter, Student Member niva Shrestha, Student Member nancy Salas, Editor

Diversity in the Physician Workforce

Are we there yet?

By Rajeev Suri, MD, MBA, FACR, 2022 BCMS President

U.S. census data consistently shows that we are becoming more racially and ethnically diverse every day in the US, and our patient populations do reflect that. These changes are however not fully re flected in the make-up of treating physicians in academic and com munity medicine and the healthcare leadership. If we want to implement diversity in the physician workforce, it can take a gener ation to implement change and another generation for this change to move up the leadership ladder.

To understand diversity trends in the healthcare workforce over the last several decades, we need to see where we’ve come from, where we are and where we need to go to. Data compiled by the AAMC (Association of American Medical Colleges) for full-time faculty in 18 clinical academic departments over 42 years (1977-2019), has shown an increase in female clinical faculty from 14.8% (1977) to 43.3% (2019); proportion of female deans rising from zero to 18.3% in the same time-period. The overall proportion of women physicians in academic and community medicine has consistently risen over the last four decades to mirror the population of women in the country.

This trend was however has not been similar for URMM (Under Represented Minorities in Medicine) where the increases have been far more modest and mixed. URMM representation even with a modest increase in the last four decades, is still not keeping pace with the population change, and the gap is further away from reflecting the US population today than it was in 2000. Growth and represen tation of black men has stagnated or decreased at all levels of aca demic medicine (faculty and chairs) and community medicine, a trend that started worsening a decade ago. Some URMMs barely registered at less than 1% in physician databases, non-Hispanic native Hawaiian/other Pacific Islander and non-Hispanic American In dian/Alaska Native.

It is a known fact that patients have better health outcomes when cared for by physicians of similar backgrounds who can relate to their life experiences. As similar disparities are also seen amongst medical students, processes need to be aimed at improving the recruitment pipeline into medical schools at the college and school level. During all aspects of premedical (school/college) and medical school train ing, there is an urgent need to identify mentors, teachers and role

models with similar backgrounds as their mentees, especially for those with diverse backgrounds. And this commitment to recruiting, re taining and developing a diverse workforce needs to continue through residency training and academic/community physician practices.

So, who can take on the mantle of delivering this? AAMC and the academic medical community has made a concerted effort for im proving diversity, but this needs a multipronged approach beyond academic medicine. Organized medicine needs to be a voice for sup porting diversity in the physician task force at the local, state and na tional level, as healthcare outcomes of a diverse population are dependent on a diverse workforce. We also need to harness the power of public-private partnerships to advance equity amongst physicians, as a component to better understanding the social and lifestyle de terminants of health equity of a population.

BCMS (Bexar County Medical Society) and its physician com munity is amongst the most diverse in the nation and closely repre sents the communities we serve. We cannot however sit on our laurels, and need to be part of a conscious effort for creating the pipeline for improving diversity in health care delivery. BCMS is partnering with local health career-focused schools and colleges, to create more robust pathways for student mentoring/shadowing with the aim to improve recruitment amongst diverse populations to fu ture health careers.

We are not there yet, but do strive to getting there soon! What’s needed is a culture change in medicine that refuses to maintain the status quo; a concerted effort from all that impacts diversity in all aspects of medical care.

References:

1. Kamran SC, Winkfield KM, Reede JY, Vapiwala N. Intersectional

Analysis of U.S. Medical Faculty Diversity over Four Decades.

New England Journal of Medicine, 2022; 386 (14): 1363

Rajeev Suri, MD, MBA, FACR is the 2022 President of the Bexar County Medical Society, Tenured Professor and Interim Chair of the Department Radiology at UT Health San Antonio, and Chief of Staff at University Hospital San Antonio.

BCMS Alliance

More Than a Social Club

By Taylor Frantz, RD, LD

In society, being a physician spouse is often glamorized. “Must be nice” is something we have all heard at least once and often it’s laced with judgment on how we must live. In reality, the members of the BCMSA are just as diverse as the community we live in, we all come from different backgrounds. Many of us work outside the home, pur suing and succeeding in careers often delayed by our spouse’s medical training. We have stay at home parents that manage the household and the mental load of being the primary caregiver. We have members that dedicate their time to helping at schools, volunteering and fundraising. We have college students, some in their twenties and others pursuing advanced degrees in the middle of their careers. Our members are both physicians and non-physicians, those in the thick of medical training and those late into their careers, men and women.

Our history dates back over one hundred years, and started out as a group of physician wives who would meet weekly to make surgical sup plies for the American Red Cross. During World War I, they worked together to complete tasks that helped their spouses such as sewing sur gical gowns, rolling bandages and knitting mufflers. Over the next one hundred years, the scope of the alliance changed as needs of the com munity arose. The alliance made pneumonia jackets for the poor in San Antonio, attended White House conferences to aid in child health ef forts, implemented programs for children on nutrition and healthy selfimagine, aided with the AIDS crisis and developed scholarships for

health care students. We continue to seek out new philanthropic op portunities in our community and step in when we see there is a need for our help.

The alliance is also a community, a coming together with other physi cian spouses that understand the unique, all-encompassing lifestyle that is being "married to medicine.” Medicine is a career that creeps into all aspects of our day to day life. From the late nights, the post-call days, the pagers, the never-ending charting, the missed holidays, weekends alone to solo parenting. Even the training to just become a physician is a brutal marathon of endless studying, high stakes exams, financially devastating loans, away rotations, etc. Even though, I was not the one going through medical school, residency or even working the long hours of “attending hood”, those challenges and accomplished were felt and celebrated just the same.

The alliance is a diverse group of physician partners that all live very different lives but are bound together by the commonality and under standing of the complexity having a physician partner. Our community service and advocacy prove we are so much more than a social club, and I encourage anyone whose partner is a physician to get involved with the BCMSA and see what we are all about.

Taylor Frantz, RDN, LD is a registered dietitian and the 2022 Presi dent of the BCMS Alliance.

Confidentiality

By Neal S. Meritz, MD

I

vividly recall a patient during the mid-80s who was a pilot for Continental Airlines. He confessed to me, that he was seriously abusing alcohol and cocaine. My legal obligation to report this was obvious, but the patient trusted me, and if I acted in the public in terest his life would have been ruined. I convinced him to enroll in a program for impaired pilots sponsored by Continental Airlines. I also remember a fourteen-year pregnant girl who had decided to obtain an abortion. She begged me not to tell her parents, especially her father. My responsibility to the law was quite clear, but the patient’s wishes were important too. I was able to persuade her to tell her mother. Ethical is sues of confidentiality such as these are commonplace.

It is a mistake to assume that an action that is legally required is therefore ethically required. Certainly, ethical obligations can conflict with legal ones. Confidentiality dilemmas are a common occurrence in the practice of medicine, especially with the use of technology vir tually unlimited.

The Hippocratic Oath has been assumed to govern doctor-patient relationships since the 5th Century B.C. It is considered a foundation for medical ethics and the provision relating to confidentiality has re mained essentially unaltered for almost 3,000 years. The doctor may not reveal any medical information told to him by the patient to any third party unless the patient provides his consent.

Hippocrates wrote, “Whatever, in connection with my professional service, or not in connection with it, I see or hear, in the life of men, which ought not to be spoken abroad, I will not divulge, as reckoning that all such should be kept secret.”

Making matters more complicated is that a doctor’s duty of confiden

tiality is not absolute. Often, multiple medical providers are involved, and the need to communicate is inherent in continued treatment. The physician must comply with the law, including the protection of the in terests of the public good, such as the investigation and prevention of serious crimes. The right to confidentiality is waived when the patient contemplates a violent act, such as suicide or possible immediate harm to another person. The provider has a “duty to warn” innocent and un involved third persons. Doctors must report certain infectious diseases, including sexually transmitted ones, that can be dangerous to the citi zenry. The physician has a “duty to protect” if child, elder or dependent adult abuse is suspected. In fact, it is mandated in every state that a pro fessional providing care for a child must notify the proper authorities if the child’s development or safety are endangered.

The universal use of technology has made it practically impossible for Americans to evade ubiquitous tracking. Confidentiality is fre quently breached inadvertently or by carelessness. In some instances, unauthorized access to patient information is intentional and criminal. Medical records may be reviewed by a multitude of friendly and un friendly eyes.

The Health Insurance Portability and Accountability Act (HIPAA) grants the right to access medical records to doctors and medical professionals, healthcare facilities which includes hospitals, labs, nursing homes, and payers such as Medicare and health insur ance companies. Technology providers that maintain electronic health records are critically important and of course, whenever it wishes, the government has access. Nonetheless, doctors and medical staff must take great care to preserve the traditions surrounding con

fidentiality while protecting the public good.

The confidential nature of the patient-doctor relationship is regarded by most physicians as extremely important, and it is taken for granted by virtually all patients. If patients wish for certain knowledge to be kept confidential even if that course of action injures their own interest, they are entitled to that privilege. The vulnerability, voluntary self-exposure and confidence sharing create special obligations to the physician to whom these gestures of intimacy and private self-revelation are made.

Good doctors prevent serious injury to others, even if that means oc casionally breaking promises. Placing the moral comfort of clinicians above the well-being of potentially violent patients and their possible victims’ conflicts with the requirements of professional responsibility. Conceivably, perils to society are no greater than those accepted when granting inviolable custody of information to priests, lawyers and bankers. Having appropriate policies in place and limiting access to confidential and sensitive information can greatly reduce the potential for disclosure of that information.

A common-sense approach, together with a working knowledge of the law and the regulatory practices should protect both the security of sensitive information and the physician from breaches of confiden tiality. Absolute confidentiality is impossible to achieve, but the teach ings of Hippocrates remain applicable in today’s world.

References

Medical Confidentiality: an intransigent and absolute obligation by Michael H. Kottow, Journal of Medical Ethics 1986, 12, 117-122

The nature of confidentiality by Ian E. Thompson, Journal of Medical Ethics 1979, 5, 57-64

In Defense of Absolute Confidentiality by Kenneth Kipnis Ph.D, AMA Journal of Ethics.org/article/defense-absolute-confidentiality 2003-10

Patient confidentiality: ethical, legal, and regulatory responsibilities, by Howard Marsh and John Reynard BJUI 2009, 104, 164-167

In the Post-Roe World, the Future of Digital Privacy Looks Even Grim mer, by Natasha Singer and Brian X. Chen The New York Times 7/13/2022

Are Medical Records Private?, VeryWell health.com 3/11/2022

Breaches of Confidentiality Aren’t Limited to High Court by Allen Smith J.D., Society for Health Resources and Management shrm.org/re sourcesandtools/legal

Neal S. Meritz is a retired Family Practice Physician, Graduated from the University of Texas Medical School at San Antonio in 1972. He is a member of the Bexar County Medical Society.

Diversity in Dermatology–A Need for More Inclusivity

By Tue “Felix” Nguyen, Bahar Momin and Marie Vu

iversity in medicine has been a long-standing issue. Re cently, there has been a push toward more inclusivity and representation within different aspects of medicine. As our minority populations grow, the diversity gap between physicians and patients will widen. The United States (US) Census predicts that from 2016 to 2060, the Black population will increase by 41.1%, and the Hispanic population will increase by 93.5%.1 Much like how diverse our patient populations are in the US, the same degree of diversity should be reflected within the physician workforce. When taking into account the different subspecialties in medicine, dermatology is con sidered the second least diverse specialty — second to orthopedics.2

D

The lack of diversity within medical schools and the medical work force stems from racial biases and systemic barriers that prevent mi norities from seeking higher education. According to the AAMC 2018 physician data, the percentages of the active physician workforce who identify as Black and Hispanic are 5.0% and 5.8%, respectively, com pared to 56.2% of physicians who identify as white.3 In dermatology, only 3% of dermatologists are Black, despite making up 13% of the US population. Similarly, about 4% of dermatologists are Hispanic, com pared to 16% of the general population.4 These percentages of minority physicians are disproportionate compared to the minority populations in the US, with dermatology demonstrating a four-fold discrepancy between physicians and patients.

Racial-discordant patient-physician relationships describe how physicians often treat minority patients of different races, which indi cate that physicians do not accurately reflect their patient populations.5 This phenomenon goes beyond needing more physical diversity and more cultural diversity. While incorporating cultural sensitivity work shops within the medical curriculum may help mitigate the adverse ef fects of racial-discordant patient-physician relationships, minority patients often express more comfort being treated by providers of the same race.6 Human medicine should not only focus on treating the dis ease but also on the patient — both in mind and body. Therefore, cul tivating a more inclusive physician workforce improves cultural familiarity and awareness during the diagnostic and treatment process, which is paramount to treating patients holistically.

When considering diversity from the patient’s standpoint, there is a lack of textual and photographic representation of skin of color (SOC)

within dermatologic educational resources.7 A study found that out of 1,123 compiled images depicting different skin diseases from various medical student resources, only 14.9% were of darker skin tones, which is again disproportionate to the actual proportion of minority groups within the US population.8 The lack of proper training in examining SOC proves challenging when attempting to accurately diagnose and treat various skin conditions in people of color (POC). Even the most seasoned dermatologists have more difficulty assessing certain skin con ditions in darker skin tones that would be otherwise easier to diagnose in lighter skin tones. The higher melanin levels camouflage erythema or alter the appearance of skin lesions from what would be considered “textbook normal.” As a result, minority patients with deeper skin tones may have poorer treatment outcomes and prognoses due to misdiag noses and delayed initiation of treatments.

So, what can be done? Some action items include:

1) Increasing underrepresented in medicine (UIM) medical students' exposure to the field of dermatology and their level of interest in it,4

2) Increasing the number of UIM students recruited into dermatol ogy residency programs,4

3) Improving SOC education in medical training.

Increasing UIM student exposure to dermatology can be accom plished by early mentorship. Frequently, minority groups are margin alized and deprived of certain advantages such as finances and social capital, which perpetuates the diversity gap in medicine. The Skin of Color Society offers a mentorship program that connects medical stu dents and young physicians to SOC experts to provide guidance, re sources and SOC education. For underrepresented students in medicine, the American Academy of Dermatology (AAD) offers a onemonth mentorship program that students can use to work on publica tions, research or clinical work. These programs can encourage students to explore the dermatology field by providing a point of contact to help guide them through the application process and cultivate their passion for the specialty.

Many dermatology residency programs have begun to offer away ro tation scholarships to UIM students. These scholarships provide fund ing to eligible students to help pay for shelter, transportation and food, mitigating the financial barriers many minority students face. In der matology, students are encouraged to rotate through as many away ro tations as possible to enrich their learning and build a professional network. Therefore, these support programs provide much-needed re sources and opportunities to these groups readily available to the finan cially advantaged. Students can research whether or not a program offers rotation scholarships by accessing the program’s website or by contacting the program’s department. The UT Health Long School of Medicine’s Dermatology Interest Group will occasionally send out in formation regarding these programs to interested members.

Properly educating medical students and residents on treating der matological conditions in SOC is a vital aspect of providing quality care to the diverse populations of San Antonio. Medical educational resources and curricula lack SOC representation for different skin dis eases. To address this lack of representation, medical schools and resi dency programs can add SOC modules to train the next generation of physicians to handle the wide variety of cutaneous presentations. The UT Health San Antonio Long School of Medicine has been integrat ing more lectures into the preclinical curriculum to educate medical students about the different morphologic manifestations in SOC. In addition, local and national conferences hosted by the Texas Derma tological Society and the American Academy of Dermatology have in corporated lectures focused on treating SOC, indicating that SOC underrepresentation is recognized even at the national level. By expos ing future healthcare providers to the diverse presentations of skin con

ditions, the misdiagnosis and underdiagnosis of patients with SOC can be minimized.

Diversity in dermatology is increasingly needed as minority popu lations continue to grow. Dermatology specializes in all hair, skin and nail conditions and should play a more prevalent role in the movement for more inclusivity and advocacy for these marginalized communities. Addressing the barriers that prevent many minorities from entering medicine will significantly close the diversity gap, improving our pa tients' therapeutic outcomes.

References

1. Vespa J., Medina L., Armstrong DM. Demographic Turning Points for the United States: Population Projections for 2020 to 2060. United States Census Bureau. 2018 March; 7.

2. Akhiyat S, Cardwell L, Sokumbi O. Why dermatology is the second least diverse specialty in medicine: How did we get here?. Clin Der matol. 2020;38(3):310-315. doi:10.1016/j.clindermatol.2020. 02.005

3. Figure 18. percentage of all active physicians by Race/ethnicity, 2018. AAMC. https://www.aamc.org/data-reports/workforce/in teractive-data/figure-18-percentage-all-active-physicians-race/eth nicity-2018. Published 2019.

4. Pritchett EN, Pandya AG, Ferguson NN, Hu S, Ortega-Loayza AG, Lim HW. Diversity in dermatology: Roadmap for improvement. J Am Acad Dermatol. 2018;79(2):337-341. doi:10.1016/j.jaad. 2018.04.003

5. Cooper LA, Neil R Powe. Disparities in Patient Experiences, Health Care Processes, and Outcomes: The Role of Patient-Provider Racial, Ethnic, and Language Concordance. The Commonwealth Fund. https://www.commonwealthfund.org/publications/fundreports/2004/jul/disparities-patient-experiences-health-careprocesses-and.

6. Hopkins Tanne J. Patients are more satisfied with care from doctors of same race. BMJ. 2002;325(7372):1057.

7. Ebede T, Papier A. Disparities in dermatology educational resources. J Am Acad Dermatol. 2006;55(4):687-690. doi:10.1016/j.jaad. 2005.10.068

8. Perlman KL, Williams NM, Egbeto IA, Gao DX, Siddiquee N, Park JH. Skin of color lacks representation in medical student resources: A cross-sectional study. Int J Womens Dermatol. 2021;7(2):195196. Published 2021 Jan 8. doi:10.1016/j.ijwd.2020.12.018

Tue “Felix” Nguyen, Bahar Momin and Marie Vu are medical students interested in dermatology at the UT Health San Antonio Long School of Medicine. They all served as clinic coordinators for the local student-run dermatology free clinic.

“You Have No Idea”

One Doctor’s Journey to Address Disparity While Combatting Burnout and Judgement

By Melissa A. Walker, DO

Several months ago, I attempted to hire back to my practice a young lady who had worked for me two times in the past. The first time, I employed her after she did her medical assistant ex ternship with me. She worked for a brief time and chose to quit because of some personal family problems. I recall this being around Christmas of that year. I remember this because my husband and I were in Dallas for a New Year’s wedding, and I called her during our trip to give her encouragement about her situation and to let her know how smart I thought she was and how I believed she had a destiny.

She cried over the phone and said that no one had ever spoken any thing positive about her. She was the mother of several children, one of whom had severe disability. Weeks later, she reached out to me de siring her job back. I did not hesitate to hire her, because not only did my heart go out to her and her situation, I also found her to be a very

skilled medical assistant. She worked for a short while but reported to me concerns about her son’s benefits being affected by her employment and therefore, she quit her job again.

Over the years, she would reach out to me randomly to say hello or to seek some proof of having worked at my office and admittedly, I con tinued to pray for her when she crossed my mind. I later learned that her son had passed away and attempted to contact her, but her phone number had changed.

With the COVID-19 pandemic has come an overwhelming issue of hiring and/or keeping staff. I initially thought it was because I have a small community practice and couldn’t offer the compensation that larger facilities could. I was soon enlightened by other colleagues from all over the country who work for larger groups and their concerns are the same. In the last several months, I have been a part of what I believe

to be either a bidding war amongst medical staff or being used as a patsy for those who need to show the social service agencies that they are at tempting to be hired. Either way, the impact of The Great Resignation has left me and so many other small business owners in a whirlwind.

My frustration and her timing are the reasons I allowed the same young lady to come for a working interview and then offered her a more formal interview. She acted excited about being back at my office and stated that “she was waiting for me to call her.” I had set up for her to do a formal interview with myself and my part-time hiring manager. Before this occurred, she began requesting reduced work hours and other accommodations for her family situation. This seemed remark ably familiar, so I tried to work with her even though she had not been hired. When I told her that I would not be able to meet all her requests, she started crying and said that I was not being understanding of her situation and that she is a single parent now. I commented that I am as well and then she spoke something that totally shocked me. She said, “yes, but everyone wasn’t born with a silver spoon in their mouth….” I thought to myself, “you have no idea….” She did not take the job being offered but went online and posted a very horrible review of me and my practice. Thankfully, I was able to have the posting taken down, but the wound in my heart was very deep. For weeks, I wrestled with the thoughts about how I have spent my medical career serving the under served, working to be a voice for the voiceless, giving services in my practice and sometimes with no financial compensation.

The thought that all doctors were “born with a silver spoon in his or her mouth” is such a false one. I know this for myself personally, but over a year ago; I had the opportunity to review some reflections that our learners wrote secondary to their participation in a Poverty Simu lation (PS). This poverty simulation was done online but bears the same concept as those that are done in person and with other healthcare pro fessionals. The goal of the PS is to place the participants in financial situations that cause stress and warrants their being creative to “make ends meet” with an extremely limited budget and with unsuspected family emergencies. With this practice, the participants should leave there with a greater appreciation for the struggles of those who are less fortunate. Many of the reflections voiced a greater sensitivity and un derstanding of those who struggle with poverty. I recall one learner wrote how he had judged a college roommate in the past for his strug gles. He wrote how he had never known any financial struggles, so it was difficult to understand why his roommate always needed some kind of assistance. Many others reflected that the PS scenarios hit close to home for them. Many wrote about how even now as a medical stu dent, they find themselves having to make modifications in spending to take care of their families with the money given for living expenses. Greater were the learners who felt the PS brought about feelings of in adequacy that they had not experienced in many years.

The online review by my former employee also introduced another phenomenon that I believe needs to have some serious reevaluation and oversight. This phenomenon is the online review process for doc tors, medical practices, etc. No one takes in account that the writer of such reviews could suffer from mental illness, have substance use dis order, be fraudulent and so much more. Yet, he or she can go online and post the most horrendous things about doctors who are doing their best to preserve the health of their patients while preserving the life of their practices.

Larger hospitals use filters to help to dispel the negative reviews, but many doctors like me do not have the time or the ability to follow such reviews and are left to bear the burden of some angry patient’s wrath.

Even with all that I have written and shared with you, I would not give up my passion or compassion towards those who are the under served and the marginalized of our community. I know that for every angry, vehement statement that has been made against me, a greater re sponse of appreciation for my assistance is shown by so many. I there fore encourage any doctor who struggles with feelings of burnout and unappreciation to meditate on this scripture:

“Let us not be weary in well doing; for in due season we shall reap, if we faint not.” Galatians 6:9

Citations

1. The Great Resignation is a phenomenon that describes record num bers of people leaving their jobs after the COVID-19 pandemic ends. World Economic Forum, November 29, 2021.

2. “Speaker, ceremonies brighten Commencement 2000; Neurosur geon shares his journey from poverty” UD Messenger, Volume 9, Number 3, 2000.

3. “Online physician reviews: Patients are the ones who will suffer,” –Kaci Durban, MD, Med Pages, August 20, 2017.

Melissa A. Walker, DO, MPA-HS, is a Primary Care Physi cian and Founder of Carol Clinic for Family-Centered Health care. She is an Assistant Professor at the University of the Incarnate Word School of Osteopathic Medicine and a member of Bexar County Medical Society.

Challenges and Opportunities in Increasing the Hispanic Participation in Our Medical Schools

By Ronald Rodriguez, MD

Nationally, there has been an improving trend in training His panic medical students. In 2015, only 6.4% of medical school matriculants were Hispanic, and the national per centage of Hispanic physicians was roughly 5%. In 2021, Hispanic medical students represented 12.7% of all medical school matriculantsup 12% from the prior year and nearly twice the rate seen only six years earlier. However, in 2019 the graduation rate of Hispanic medical stu dents was 5.3% (Figure 1), closer to the current national estimates of Hispanic physicians in the US (5.8%). Presumably, with more time, the increased matriculation rates will translate to increased Hispanic physicians, but only if the production of such physicians occurs faster than attrition of these physicians and if the graduation rates of these Hispanic medical students are comparable to non-Hispanic white stu dents. While these results are a step in the right direction nationally, the physician shortage in Texas, particularly in San Antonio and the greater South Texas region, is much more concerning.

In the first quarter of 2021, there were 1.674 million healthcare and social assistance employees in Texas, up 6.3% from the same quarter in 2016. Growth occurred despite the harmful economic impact of the COVID-19 pandemic. Healthcare and related jobs will continue to be the most dominant industry in Texas moving forward, as the growing population of the elderly and the young are projected to be among the highest in the overall population.1 Healthcare jobs in the Alamo work force development area are expected to grow at least 27% over the next five years, more than any other occupation in this region. Despite sig nificant underestimates in the Latino community from the 2020 Cen sus,2 at least 66% of the population in the San Antonio area is Hispanic, and 7% are black, while 22% of the physicians are Hispanic and 3% are Black. Compared to national Hispanic physician rates, these are im pressive numbers. But compared to the local demographic, the fold dis parity in the San Antonio area is no different from the rest of the nation (Figure 2). The disparity among Hispanic/Latino providers is even more disturbing when looked at geographically (Figure 3). Nearly all primary care providers have offices in the medical center and the Northside, with relatively few providers located South of Highway 90. The Southside is a predominantly Latino community (>90%), with high disease morbidity but relatively little access to care. Additionally, the income disparity between the North and South is among the high est in the nation for any large metropolitan area.3 According to the AAMC, between 2019 and 2034, the Hispanic population is projected

Figure 1. Race/Ethnicity of Medical School Graduates 2018-2019, USA.

to grow by 32% nationally.4 In the San Antonio area, this would predict 87% Hispanic by 2034.

In order to address the current and changing demographic, our medical schools need to attract and train more Hispanic students. At first glance, the increased number of physicians trained locally through UT Health San Antonio and the relatively new UIW School of Osteopathy look encouraging to meet this local need. However, while the national average matriculation of Hispanic medical students was 12.7% com pared to an 18.4% national Hispanic population, the local matricula tion of Hispanic students in 2021 was 19.6% (UTHSA) compared to a local Hispanic population rate of 66%. This translates to a 1.4-fold disparity nationally but 3.3-fold disparity locally. Even with some of the highest Hispanic matriculation rates in the country, the local train ing of medical students is falling well short of even the national average. These data predict some stark realizations, including:

1. We cannot rely on meeting our local needs for Hispanic physi cians by local training alone. We must find solutions that make San An tonio a favored destination for Hispanic providers. Currently, as our

Figure 2. Hispanic Physician Disparity.

Hispanic physician disparity is identical nationally and locally (Figure 2), San Antonio is not any more attractive a site for Hispanic doctors as the rest of the nation.

2. We must escalate our investing in our pipeline programs (at the High School level or even earlier) with culturally sensitive preparation for health careers. Fortunately, we have two health careers high schools in San Antonio which are actively engaged in this process. Our efforts to support the Health Professions High School and the newer CASTMED High School must be expanded. Additionally, efforts must be focused on enhancing cultural sensitivity training for our students while engaging them in the community to empower them and develop a strong desire to stay in the area.

3. The academic and business community must identify and pro mote newer innovative methods of recruitment and retention of His panic providers by providing career advancement opportunities that reward success in promoting diversity, and hold strict accountability for those leaders who do not demonstrate continuous improvement in those domains.

In summary, we are at a critical inflection point in the changing de mographic of the nation and our beloved community. We are the only top-10 city in the nation with a majority-minority population, and this community’s Hispanic predominance will continue to grow. There is substantial healthcare disparity in our community due in part to an im possibly complex healthcare system, which is systemically structured to place our most vulnerable patients at a disadvantage. Additionally, not enough of our providers reflect the language, culture and sensibil ities of the communities they serve. If we don’t take active measures to our approaches to our local biomedical and healthcare enterprise, these disparities will only widen. But despite these stark warnings, San An tonio is a community of immigrants, and a melting pot of cultures

Figure 3. Primary Care workforce supply mapped geographically. Note the large geo graphic disparity for availability of primary care providers. Data provided by Sg2 Healthcare analytics.

which for centuries have demonstrated the most profound resiliency. The COVID-19 pandemic demonstrated a glimpse of the immense vulnerabilities of our at-risk populations. However, I believe that with strong leadership, community engagement, and thoughtful collabora tion between the business and academic communities, we can solve these problems and brighten our future.

Ronald Ridriguez, MD, PhD is a Professor of Urologic Science at UT Health San Antonio. He is also a member of the Bexar County Medical Society.

References:

1. Commission, T.W., Report on Texas Growth Occupations. 2021, State of Texas: https://lmci.state.tx.us/shared/PDFs/High-GrowthAnnual-Report-Final-Review-full-2021.pdf. p. 1-94.

2. United States. Congress. House. Committee on Oversight and Re form, Reaching hard-to-count communities in the 2020 census : hearing before the Committee on Oversight and Reform, House of Representatives, One Hundred Sixteenth Congress, second session, January 9, 2020. 2020, Washington: U.S. Government Publishing Office. iv, 79 pages.

3. Bureau, U.C., US Census, Document S2001: Median earnings of those who worked full-time, year-round in 2020, filtered to Bexar County, U.D.o.C. , Editor. 2020.

4. AAMC The Complexities of Physician Supply and Demand: Pro jections from 2019-2034. 2021.

Call To Action–

UT Health Students Address Need for Accessible Chronic Disease

Self-Management Among the San Antonio Refugee Population

By Mahima Ginjupalli and Salma Yazji

very Wednesday evening, student and faculty volunteers from UT Health San Antonio (UTHSA) unlock the doors of St. Francis Episcopal Church and welcome the line of refugees seeking free, culturally informed health care. UTHSA and the Center for Refugee Services of San Antonio partnered in 2011 and es tablished the San Antonio Refugee Health Clinic (SARHC), with the mission of addressing and promoting the interdisciplinary health and social needs of thousands of refugees living in northwest San Antonio.

E

The COVID-19 lockdown in the spring of 2020 forced the clinic to abruptly close its doors for the first time in years. The patient vulnera bility that resulted from this cessation of services kickstarted the efforts of faculty, medical, dental and nursing students to design and imple ment the first clinic telehealth outreach. A large-scale needs assessment exposed the heightened struggles faced by refugee patients with dia betes and hypertension without consistent access to care. This discovery led students to develop the Community Service Learning (CSL) proj ect, which is still in operation today.

Backed by grants from UT Health's Center for Medical Humanities and Ethics, the CSL project is a collaboration between faculty, stu dents, family medicine residents, local dietitians, community inter preters and volunteers.

This program recruits refugees with uncontrolled diabetes and hy pertension and provides them with culturally and linguistically con scious tools. It also provides the knowledge and continuous support to self-manage their chronic diseases.

These efforts include providing free at-home glucose and blood pres sure monitors, hosting regular group seminars and one-on-one consul tations with dietitians in patients' respective languages, medication management and regular clinic visits with primary care physicians. Stu dents contact participants monthly to gather glucose and blood pres sure readings, ongoing barriers and future needs.

In the late of 2020, 97 identified patients were contacted and 30 pa tients expressed interests in the program. An average of 14 participants across five language groups (Arabic, Burmese, Nepali, Rohingya, Span ish) attended the educational seminars and scheduled appointments. These participants are a mix of recurring and new members; however, the program has greatest difficulty with patient retention. Patients struggle most with food and transportation insecurity, along with de manding work and home obligations that complicate their ability to regularly attend sessions and record their measurements at home.

Over time, the team has made changes such as offering transporta

tion to the seminars, setting up a multilingual WhatsApp group for carpooling, and increasing community support. The team is also look ing to make the sessions and one-on-one appointments accessible on a virtual basis. Given difficulties in consistently recording glucose and blood pressure measurements, student volunteers will triage patients at the monthly appointments to get this data and ask for general aver ages of measurements at home. Lastly, the team is developing a new partnership with the San Antonio Food Bank for at-home delivery of free groceries for participants with reported food insecurity.

As members of the team transition in and out, the program contin ues to provide accessible community-based education and follow-up services for refugees in need. Ultimately, the goal is to graduate partic ipants who have shown the ability to self-manage their conditions and can transition with the help of social workers into the traditional healthcare system. The program also aims to implement graduated par ticipants as community ambassadors to shape future iterations of the program in a way that best serves their respective communities. To the team, one thing is clear: chronic disease management does not have a one-size-fits-all solution. This form of primary care, further under-ad dressed among vulnerable communities, requires the ability of providers to learn from their populations and evolve their care to suit their community's needs in a manner that goes beyond the reading on a blood pressure cuff.

Salma Yazji is a medical student interested in Psychiatry at the UT Health San Antonio Long School of Medicine, Class of 2023. She serves and works as a student co-leader at the Refugee Health Clinic.

Mahima Ginjupalli is a medical student interested in Psychi atry at the UT Health San Antonio Long School of Medicine, Class of 2023. She serves and works as a student co-leader at the Refugee Health Clinic.

Secondary authors: Aden Tadese, Ojasvie Agnihotri, Zachary Harbin, Natalya Ponomareva, Sehwa Nick Kang, Ariana Maleki, Zuha Alam, Serena Luke, Reem Farra RD, Rosalynda Rodea RD, Carolina Gutierrez Garcia, MD, Esther Shin MD, Etny Candelario, MD, Khorshid Amirk hosravi, MD, Tara Toloui, MD, Fehima Dawy, MD, Lizzette Lugo, MD, Armando Flores, MD, Carolina Sanchez, MD, Sabeen Abdullah, Zainab Essaji, Munawar Iqbal, Fozia Ali, MD.

Establishing a Chronic Disease Self-Management Program at San Antonio Refugee Clinic

By Mahima Ginjupalli and Salma Yazji

Aden Tadese, Ojasvie Agnihotri, Zachary Harbin, Natalya Ponomareva, Sehwa Nick Kang, Ariana Maleki, Zuha Alam, Serena Luke, Reem Farra RD, Rosalynda Rodea RD, Carolina Gutierrez Garcia, MD, Esther Shin MD,Etny Candelario, MD, Khorshid Amirkhosravi, MD, Tara Taloui, MD, Fehima Dawy, MD, Lizzette Lugo, MD, Armando Flores, MD, Carolina Sanchez, MD, Sabeen Abdullah, Zainab Essaji, Munawar Iqbal, Fozia Ali, MD The University of Texas Health Science Center at San Antonio

Statement of the Problem

The San Antonio Refugee Health Clinic (SARHC) is a student-run free primary care clinic for refugees from over 20 countries. A partner ship between UT Health San Antonio and Center for Refugee Serv ices, the clinic promotes the wellness and self-sufficiency of resettled refugee families. During the COVID-19 pandemic, telehealth efforts determined that chronically ill patients were disproportionately af fected by clinic closure. Subsequently, outreach was done to assess pa tients’ efficacy in diabetes and hypertension self-management to develop a six-month intervention.

Materials and Methods

• Initial patient outreach and survey administration took place from October - December 2020. Responses lead to the development of a sixmonth program that began in June 2021 with three in-person seminars and remote monthly surveys. During each seminar, distribution & training with blood pressure cuffs and glucose monitors was done, along with nutritional counseling and recording of initial body com position data. Returning participants received gift cards and had med ications refilled

• Monthly phone call check-ins with MS2s and FM residents were con ducted to gauge at home monitoring.

• After the final seminar in January 2022, we analyzed data from the pre-and post- program surveys and patient longitudinal quantitative data using a paired t-test. Results

• Of over 100 individuals contacted, 14 new participants from five language groups (Arabic, Burmese, Nepali, Rohingya, Spanish) at tended the initial seminar on 6/30/21. Nine new participants and five returning participants attended the second seminar on 10/27/21.

• 65% of participants have hypertension. 56.5% have type 2 diabetes.

• The average initial A1C levels for our diabetic participants are above the recommended 7% or less, demonstrating an overall shared problem with glucose control.

• The average initial BMIs for all groups are either overweight or obese. Our goal is to help lower these values through the healthy interventions we are implementing.

• The initial pre-survey identified that regular self-monitoring is an area for improvement.

• The monthly follow-up calls showed that half of the participants re ported checking their levels regularly; however, only 30 - 37.5% recorded and shared this information.

Figure

Flyer

to recruit community members.

• At monthly follow-ups, the most common response for ongoing bar riers to tracking glucose/blood pressure included limited time and work. The most common response for ongoing barriers to healthy diet and physical activity included limited food access, chronic pain, neigh borhood safety and limited transportation.

• In total, of the initial 14 participants, only 2 individuals attended all three seminars. As such, the data is not significant enough to merit quan titative analysis. Plans are currently being made for another six month follow through with changes to the current organization of the program.

Conclusions and Recommendations

● This is an ongoing project to assess effective ness of culturally and linguistically accessible community education, and follow-up for pro moting self-management of chronic conditions among refugee populations.

●

While the final turnout was much less than anticipated, this project serves as a lesson of cultural competency and applied research ed ucation. Plans are under way to address the needs identified during our first iteration.

● Plans for the upcoming cycle include modi fications such as a multilingual WhatsApp group to share transport needs and increase en gagement, one-on-one monthly in-person di etician and provider check-ins rather than phone calls, and collaboration with SA Food Bank delivery service.

Acknowledgements

Margaret Costantino, Director of Center for Refugee Services

UTHSCSA Community Service Learning Grant

References

1. Adel, Fadi W., et al. “San Antonio Refugees: Their Demographics, Healthcare Profiles, and How to Better Serve Them.” PLOS ONE, vol. 14, no. 2, 2019, doi:10.1371/journal.pone .0211930.

2. Harbin, Z., Yazji, S., Ginjupalli, M., et al. (2021, March). San Antonio Refugee Health Clinic COVID-19 Telehealth Response and Cross-Sectional Study of Refugee Population Needs During the Pandemic. Poster presented at 2021 Society of Student Run Free Clinics Conference.

Between the Lines

The Origins of Auscultations, A Storytelling Project

By Winona Gbedey

n the morning of May 26, 2020, I bounded down the stairs like I did every other day, wiping the sleep from the corner of my eyes. On with the kitchen lights and out with the dog. Breakfast, which consisted of a mug of hot water, laden with green tea; two frozen waffles, heated in the toaster oven; and a banana, sliced into even pieces. After I slathered chocolate hazelnut spread over my waffles and carefully arranged my bananas on its surface, I settled onto the couch with my food and clicked the television on to the morning news. Breaking news: George Floyd, a 46-year-old Black man, had passed away the night before after sustaining fatal in juries in police custody.

O

Mr. Floyd’s death sent ripples through our nation, quickly splintering our country into three groups: 1) those who stood with the protestors and shouted for change; 2) those who wanted to engage but needed to learn more first; and 3) those who vehemently disapproved of the shift ing tides. I straddled the line between the first and second groups. Like any self-respecting millennial, I took to the internet. Anger and frus tration fueled me as I documented my experiences as a first-generation Black woman on my Facebook page. To my surprise, friends and col leagues alike used my social media posts as jumping off points to share their own stories, spurring passionate conversations about adversity and social justice in the comments.

As it turns out, I wasn’t the only one using storytelling as a vehicle for change. All across the nation, well-intentioned individuals were asking their minority friends to share their unique experiences as people of color. And each request ended with a similar plea: Teach me how to be a better advocate for you. Unbeknown to them, they were putting the im pedance on their friends to do “the work” for them by ask ing them to relive past trau mas, dig through misinfor mation, and make them selves vul

nerable to potential criticism and retaliation.

I quickly learned that what I had been doing -- documenting my ex periences and encouraging meaningful dialogue among my peers -- had become yet another hurdle for others to jump over while wading through their own emotional baggage. While I had volunteered my stories, they had not. There is value in trading experiences, but not when they are not freely given.

Six likeminded classmates and I came together to safely bring these conversations to the UT Health San Antonio community. Each cofounder was as hungry for change as I was. Our connection to various marginalized identities tethered us together. George Floyd, and the re sultant fracturing of our country, guided our mission. Our shared in terest in storytelling supplied our “how.”

We called ourselves Auscultations.

At its root, auscultation simply means “to listen.” Listening is the heart of our organization. Auscultations provides a stage for willing participants from various disadvantaged backgrounds to share their stories. Audience members are able to learn from their experiences as well by anonymously submitting questions online, which are then screened and asked by our moderators. Through this process, we have created a safe space where students are both teachers and learners, or ators and auricles. From struggling with mental health at the height of the COVID pandemic and paying the “minority tax” as a homosexual Hispanic male, to reconciling the hopes of the American dream with the reality of racism and persevering despite subpar pre-medical grades and MCAT scores — our community continues to grow as we enter our third year of biannual storytelling events and written featurettes.

Why storytelling? Author and activist Chimamanda Ngozi Adichie summarizes it well in her 2009 TEDTalk, “The Danger of a Single Story.” Adichie argues that every person, every culture, every place, con sists of many overlapping stories. Together, these stories fit together like pieces in a puzzle, revealing something unique and beautiful. Apart, they depict an incomplete image that often contributes to misunder standings, anger, and prejudice. In short, stories are powerful.

I often watch our storytelling events from behind the scenes as I work with the other co-founders to manage technical difficulties, gather anonymous questions, brainstorm backup questions, and ensure seamless transitions from one storyteller to the next. Yet, my ears re main perked. At Auscultations, diversity is both welcomed and em

braced. But while our speakers share the triumphant and traumatic parts of their life’s story, the parts that brought them to our virtual stage, a similar undercurrent runs behind their words: there is no one right way to become a physician, just as there is no one right way to study chemistry, mourn the loss of a beloved pet, or raise a child.

During our storytelling sessions, I am often reminded that our unique identities and experiences entwine to create a rich tapestry of life experiences that inform our beliefs, our decisions, and our relation ships. It is unfortunate that tragedies often open the doors for us to share these parts of ourselves, to connect, though begrudgingly. It is our duty to remind ourselves that our differences are still something to be cherished in the interim.

It cannot be denied that our focus on diverse experiences also has positive implications for our future patients. Over the decades, medical schools have made a concerted effort to recruit classes that more accu rately reflect the increasingly diverse population of the United States.1 Countless studies have shown how racial, ethnic, and gender diversity among health professionals promotes better access to healthcare and improves healthcare quality for underserved populations.2 Interacting with people with different experiences allows us to empathize better, in both the best of times and the worst of times.3

Auscultations was born from tragedy, yes, but we believe there is

something to be learned from our stories.

References:

1. Medical school enrollment more diverse in 2021. AAMC. (2021, De cember 8). Retrieved August 20, 2022, from https://www.aamc.org/ news-insights/press-releases/medical-school-enrollment-more-di verse-2021#:~:text=Diversity%20of%20the% 202021%20enter ing%20medical%20school%20class&text=The%20number%20of% 20Black%20or,up%20from%209.5%25%20last%20year.

2. AMA adopts new policy to increase diversity in physician work force. American Medical Association. (2021, June 17). Retrieved August 20, 2022, from https://www.ama-assn.org/presscenter/press-releases/ama-adopts-new-policy-increase-diversityphysician-workforce

3. Charon, R. (2001, October 17). Narrative medicine. JAMA. Re trieved August 20, 2022, from https://jamanetwork.com/ journals/jama/fullarticle/194300

Winona Gbedey is a medical student at the UT Health San An tonio Long School of Medicine, Class of 2023. She is a cofounder of the student organization, Auscultations. She is a member of the BCMS Publication Committee.

Perspective on Care for the Transgender Patient Experiences from the PRIDE Clinic

By Joshua Carrasco, Louisa Xie and Brent Arcayan

Over one million transgender individuals, including trans feminine, transmasculine, non-binary, gender-noncon forming and gender-diverse (trans) individuals live in the United States (Meerwijk & Sevelius, 2017). “Trans” serves as an um brella term that includes all people who do not identify with their sex assigned at birth, whether that is female or male. This assignment is most often given at birth based on phenotype and genotype; however, we know that having only two options “biological male” or “biological female” does not fully capture the complex variations that can occur in disorders of sexual differentiation (García-Acero et al., 2020). Thus, gender is more nuanced than sex assigned at birth. Gender identity is how one feels inside and how those feelings are expressed through clothing, appearance and other behaviors. Martin and Ruble (2010) found that this inner sense of gender identity develops between the ages of three and five while most people feel they are either male or female, some people may feel both, neither or somewhere else along the spectrum of gender.

Gender transition is a multifaceted process. People can change their name and gender marker on identification documents. Not all trans people transition, nor do they transition in the same way. Some may choose to transition only socially and forego any medical transition which would entail hormone therapy and gender-affirming surgeries.

Barriers

Transgender individuals may face discrimination in a multitude of environments. Investigative studies have captured anti-trans discrimi nation and bias and its negative effects on the trans community (Grant

et al., 2011). Individuals within the trans community disproportionally report worse health outcomes. When compared to their cisgender counterparts, trans adults are more likely to report poor mental health, higher rates of substance abuse and greater reports of being physically or sexually assaulted. A staggering 81% of trans respondents have con templated suicide, compared to just 30% of cisgender adults (Grant et al., 2011).

The number one barrier faced by the community is a lack of access to providers that are knowledgeable about the special care they may re quire (Safer et al., 2016). The inclusion of transgender-informed health care in medical school or residency curricula is not widely standard. Other barriers to care include stigma, self-perceived or experienced and cost. While research identifying barriers to care for transgender indi viduals has solidified, solutions for addressing these barriers remain.

Trans Care is Health Care

According to Paine (2021), “trans broken arm syndrome” is under stood, colloquially, as the phenomenon that occurs when physicians attribute a trans person’s health concerns and conditions solely to their hormone replacement therapy (HRT) without engaging in further di agnostic workup, for example, a trans-masculine patient’s hyperlipi demia may be chalked up to their testosterone use and brushed aside.

Medical residents have reported a lack of formal education in trans care, specifically HRT and screening guidelines. Survey of internal medicine residents at a large urban academic center (Johnston & Shearer, 2017) revealed that the majority did not have knowledge of how to provide HRT, cervical cancer and STI screening or explanations

of gender-affirming surgery. These results have been replicated in other surveys of physicians (Potter et al., 2015) and create barriers to care for transgender patients seeking routine and gender-affirming care because of physician uncertainty, hesitancy, and discomfort. According to the American College of Obstetricians and Gynecologists (2021), profes sional guidelines for routine cervical cancer and STI screening in trans patients are identical to those recommended for cisgender patients. Ul timately, trans health should be included throughout medical training. Trans patients should feel confident that their primary care physicians have adequate training to care for and help people make informed de cisions about their care.

The Clinical Practice Guidelines from the Endocrine Society is a good resource for physicians when prescribing HRT and caring for trans patients. These guidelines provide diagnostic criteria for gender dysphoria in adults and children. They also provide valuable infor mation on monitoring for adverse effects and long-term outcomes. Clinical Practice Guidelines are used at UT Health San Antonio’s Pride Community Clinic, a Student-Faculty Collaborative Practice at the Long School of Medicine that serves LGBTQ+ patients in Bexar County.

To learn more about physician advocacy for transgender individuals and improving the wellbeing of the trans community in medical spaces, please visit the following informational websites.

The Pride Center San Antonio: https://pridecentersa.org/

American Medical Association, Creating an LGBTQ Friendly Prac tice: https://www.ama-assn.org/delivering-care/population-care/cre ating-lgbtq-friendly-practice

Texas Medical Association: LGBTQ Health: New TMA Section Helps Physicians Treat a Mis understood Population (texmed.org)

References

1. Meerwijk, E. L., & Sevelius, J. M. (2017). Transgender Population Size in the United States: a Meta-Regression of Population-Based Probability Samples. American journal of public health, 107(2), e1–e8. https://doi.org/10.2105/AJPH.2016.303578

2. García-Acero, M., Moreno, O., Suárez, F., & Rojas, A. (2020). Dis orders of Sexual Development: Current Status and Progress in the Diagnostic Approach. Current urology, 13(4), 169–178. https://doi.org/10.1159/000499274

3. Martin, C. L., & Ruble, D. N. (2010). Patterns of gender develop ment. Annual review of psychology, 61, 353–381. https://doi.org/10.1146/annurev.psych.093008.100511

4. Grant, J. M., Mottet, L. A., Tanis, J. J., & Min, D. (2011). Trans gender Discrimination Survey. National Center for Transgender

Equality and National Gay and Lesbian Task Force: Washington, DC, USA

5. Safer JD, Coleman E, Feldman J, Garofalo R, Hembree W, Radix A, Sevelius J. Barriers to healthcare for transgender individuals. Curr Opin Endocrinol Diabetes Obes. 2016 Apr;23(2):168-71. doi: 10.1097/MED.0000000000000227. PMID: 26910276; PMCID: PMC4802845.

6. Paine E. A. (2021). "Fat broken arm syndrome": Negotiating risk, stigma, and weight bias in LGBTQ healthcare. Social science & medicine (1982), 270, 113609. https://doi.org/10.1016/j.soc scimed.2020.113609

7. Johnston, C. D., & Shearer, L. S. (2017). Internal Medicine Resi dent Attitudes, Prior Education, Comfort, and Knowledge Regard ing Delivering Comprehensive Primary Care to Transgender Patients. Transgender health, 2(1), 91–95. https://doiorg.libproxy.uthscsa.edu/10.1089/trgh.2017.0007

8. Potter, J., Peitzmeier, S. M., Bernstein, I., Reisner, S. L., Alizaga, N. M., Agénor, M., & Pardee, D. J. (2015). Cervical Cancer Screening for Patients on the Female-to-Male Spectrum: a Narrative Review and Guide for Clinicians. Journal of general internal medicine, 30(12), 1857–1864. https://doi.org/10.1007/s11606-015-3462-8

9. American College of Obstetricians and Gynecologists’ Committee on Gynecologic Practice, & American College of Obstetricians and Gynecologists’ Committee on Health Care for Underserved Women (2021). Health Care for Transgender and Gender Diverse Individuals: ACOG Committee Opinion, Number 823. Obstetrics and gynecology, 137(3), e75–e88. https://doi.org/10.1097/ AOG.0000000000004294

Joshua Carrasco is a medical student interested in Pediatrics at the UT Health San Antonio Long School of Medicine, Class of 2023. He serves and works in front of the transgender flag at the Pride Community Clinic.

Louisa "Lou" Xie is a medical student interested in Internal Medicine at the UT Health San Antonio Long School of Medi cine, Class of 2023. Lou Xie serves and works in front of the transgender flag at the Pride Community Clinic.

Brent Arcayan is a medical student interested in Internal Medicine at the UT Health San Antonio Long School of Medi cine, Class of 2023. Brent Arcayan serves and works in front of the transgender flag at the Pride Community Clinic.

Wound Healing

By Winona Gbedey

My history is carved deep into my skin, A rich tapestry of what was, What will be, And what could have been. These stories, They’re mine to keep And mine to tell.

So, dissect through my walls Like a specimen on your table. Let my body be your guide.

Peel away parts of me Until you find What stitched me back to life.

One day we’ll reach The very core of my being, And you’ll see what gave me these scars.

Author’s Note: The inspiration for this piece struck me late at night while reviewing for the first musculoskeletal weekly quiz. Scar formation. I thought it fascinating how several lay ers of skin must be breeched before our bodies decide to me morialize our injuries. This got me thinking about my own scars, and how they merely serve as reminders of funny stories to tell my friends. Emotional scars, though, they’re different. They inflict so much pain without even piercing the skin. Somehow, they cut deeper than physical wounds. This poem explores that dichotomy.

Winona Gbedey is a medical student at the UT Health San Antonio Long School of Medicine, Class of 2023. She is a co-founder of the student organiza tion, Auscultations. She is a member of the BCMS Publication Committee.

More Than a Diagnosis

By Lauren C. Jameson

Missed appointments, lack of response Life has not been easy for you How can I learn more about your needs and wants? I am here to listen to what you’ve been through

Why are you afraid of him? The man to whom you were once wed Did he hurt you, make you a victim? When he calls and threatens you, what words are said?

HIV positive and blood sugar rising Food insecurity and no car of your own Feelings of depression you’ve been disguising You are so much more than what your labs have shown

You are more than a diagnosis, a problem to treat You are a human being with value – intrinsic and complete

Author’s Note: I wrote this poem as a letter to one of my pa tients who was lost to follow-up. I wish I had the opportunity to tell her, that she is not alone and that there are many re sources we can connect her with.

Lauren C. Jameson is a student at the UT Health San Antonio Long School of Medicine, Class of 2023.

The Gifts of Orion

By Dawson Tan

This is a composite image of 60 pictures of the Orion Nebula taken with a mirrorless camera. The Orion Nebula can be seen in the center while the Flame and Horsehead Nebulae are in the top left of the image. To the right is the bright star, Tau Orionis. All of these are located within the constellation of Orion. This was my first attempt at capturing a deep sky object. I started astrophotography during my first year of medical school and it has been a great way to take a break from studying.

Dawson Tan is a student at the UT Health San Antonio Long School of Medicine, Class of 2025.

How I Got Here

By Yousef Salem

According to the Association of American Medical Colleges (AAMC), 80% of admitted students come from the top 40% of income nation wide. This is my story from the bottom 20%.

When I was eight, my family did not have a stable income, so I helped my mom apply for food stamps. We received the bare minimum amount for food, $300/month for our entire family and we played a game of stretching that as long as possible. But we never made it to the last week. It just had to suffice.

Over nine years, we rode a rollercoaster of ups and downs, where our situation improved briefly, and then an unexpected car repair or a high utility bill would add pressure again. We knew exactly how long it took before getting cut off from electricity and water. Sometimes we made it without. We dreaded going home after school where there was no A/C or lights.

After graduating high school, I applied to university even though I couldn’t actually afford it, but everyone around me was doing it. I applied for a scholarship and was rejected, so I reached out to Financial Aid to explain my situation. I got lucky in finding someone who empathetically walked me through the appeals process. Thankfully, I won the scholarship, which meant I could work less while helping keep a roof over our heads. Between this increased stability, further hard work, and many other lucky breaks, I was able to focus on studying medicine, and now here I am.

At some point, we will treat “non-compliant” patients who need to feed their kids. Or they delay treatment until the point of no return because they had to pay rent. I am thankful for my experiences as they allow me to better understand the difficulties these patients face and I hope to see more students in medical school who have overcome similar challenges.

Yousef Salem is a student at the UT Health San Antonio Long School of Medicine, Class of 2024.

55 Word Stories – On Kindness

By Medical Students

These stories are written by medical students in the Long School of Medicine at UT Health San Antonio and reflect the diversity of their pa tients’ lives and their own experiences in caring for them. They emphasize the importance of looking closer at each patient as an individual with their own unique identity, language, values, culture and hope. And by honoring the humanity of their patient, each student seeks to pay attention to their own.

Alone

I took a moment to collect my thoughts and walked into her room. She was intubated and clearly dejected. This was her second time presenting in myasthenic crisis and she hated that she was in the hospital again. I tried to console her but my words bounced off.

She wanted to be alone in her suffering.

By Ritwick Mynam, Class of 2023

Why didn’t you ask her pronouns?

I’m sure you meant no harm. You took an oath to do no harm. I’m sure you felt uncomfortable. I’m sure you were rushed. But you hurt her. She came to us asking for help, just wanting to breathe. You made an assumption. You called her, “him,” a pronoun she has despised her whole life.

This is a story about a transgender patient who was mis-gendered by someone else. This hap pened before I walked in the room to intro duce myself. It took me less than five seconds to ask her, “what are your pronouns?” She re sponded, “she/her/hers,” with a smile on her face. I immediately felt that I had gained her trust. I will take this experience forward with me in my future practice of medicine. We are busy. We work long nights sometimes. It

might be uncomfortable to ask patients what their pronouns are, but it makes a difference. Our patients have likely experienced discrim ination in the past, and we need to remember that. We need to create a safe space within our hospital. It only takes a few seconds to ask, “what are your pronouns?”

By Jacob Houser, Class of 2023

Polka dots on his chest CT

He came in with shortness of breath. CXR, CT, and bronchoscopy showed why.

He said, “I used to have cancer. They removed it in that surgery last November.”

He thought he was cured. I’m now saying he wasn’t.

He said, “I’m sorry, translator, could you repeat that?”

I said, “Tiene cancer en sus pulmones, señor.”

This patient had a right radical orchiectomy last year. He believed he was cured since they removed the source of his cancer. What I won der though is if the patient truly understood the extent of his disease or his postoperative management, and the reason I ask this is be cause the patient is Spanish-speaking and I think about the possible breaks in communi cation with the language barrier. Was the care team able to properly convey the information about the patient’s cancer, his treatment plan and his prognosis? I’m not sure because the patient truly believed he was completely cured after surgery. I believe we have to make each

and every effort to confirm understanding in our patients. When that involves an initiation or change in the treatment plan, teach-back is commonly used. When a highly sensitive matter such as the diagnosis of cancer is involved, I think the discussion needs to be more inclu sive of everyone on the treatment team so that the patient may fully and wholly understand the plan moving forward.

By Megana Challa, Class of 2023

His family kept offering us food Coughing and gasping, satting 75%, he said in his own language, “I was born with a funny heart.”

No doctors here would touch him, too afraid of causing harm, so he sat throwing septic emboli into his lungs. Still, his brother offered us sweets, “You’re the doctors, you know what’s best, Thank you so much.”

This experience was really poignant for me be cause this patient was a refugee from Afghanistan, and a lot of the cultural view of medicine is very similar to what my own family members in India express. Even though the pa tient was really afraid, he blindly trusted us to do the right thing and his family also didn’t question us. As a provider, it was frightening for me to have that much absolute faith placed upon the words I said. I feel that in the Western world, we are very used to patients and families asking questions, wanting more clarification and even disagreeing with us. In that way, it’s

much more of a two-way street rather than a paternalistic approach, as is still common in many parts of the world. I think it is very im portant for us as providers to recognize the cul tural differences of patients who might be approaching us from backgrounds where doc tors aren’t questioned. It is important to not just expect them to ask us questions for clarifi cation, but speak up when they feel that we are not doing right by them. Similar to my own culture, food is a very important way of bond ing. Sweets in particular are hand selected for moments of joy and celebration. To accept sweets from this family, who literally have nothing as they flee from their home country, especially when I feel as if I am doing nothing to help their suffering family member, felt wrong. I know that I will carry this experience with me throughout my career. The days and days we spent waiting will drive me to be a stronger and louder advocate for my patients. Perhaps as a medical student, I was too timid and I did not have any real authority, but I re fuse to let my patients be sidelined again.

By Anjali Prasad, Class of 2023

Chasing a future on false hope I’m in so much pain that I have to drink. I’ve run out of pain meds. I’ll be better when I have my surgery. I promise I won’t drink. I’m going to be a preacher when I’m off the streets and better. Sorry, doc, I promise I won’t drink again. The pain…it’s just so bad.

By Evan Caston, Class of 2023

Promising future. Stranger now. The pride of a loving mother and father Role model

Left to serve Came back lost He was alone filled with anger, confusion and fear

Worried parents call every day in hope  The remnants of who he is surface occasionally, but are overshadowed by a new identity

He is still the son of loving parents.

This experience impacted me deeply. I was randomly placed to speak with this patient on psychiatry and was told a brief history. Upon more chart checking and history taking, it seems this patient went to serve in the military but he never returned the same. He was diag nosed with schizophrenia. I spent many days speaking with him and his family, only to learn more and more about this person who was in military training before. I could hear the pain in his parent’s voices. I learned what it meant to help a patient holistically. I learned that this patient although on a cursory look seemed like an agitated individual, who was intimidating to speak with was truly the pride and joy of two loving parents, who wished nothing more than to have the son they once knew. I realized that oftentimes it is easy to get lost in the mun dane life of a physician and only when you take a step back and truly introspect on what it means to be a physician and how you impact others will you truly remember why it is re warding.

By Subhash Venigalla, Class of 2023

Nothing feels worse than false promises

A sigh of relief, exhausted eyes look hopefully at the clock.

Days and nights blending together under the fluorescent sun, nothing seems more relevant than going back home.

Door opens up, expression hidden by mask. Every word, a hammer heavily brought down on hopes of escape.

Door clicks shut, nothing feels worse than false promises.

I chose this story due to the frequency these thoughts occur in both physician and patient and to emphasize that everyone in the hospital is a person with their own agendas and feel ings. Recognizing your own as well as others can put things into perspective.

By Aaron Fanous, Class of 2023

All she asked for was chapstick

It all happened so fast. She was vomiting so much blood.

She agreed to intubation, just asking that we use chapstick for her dried lips. She coded after intubation. Still bleeding. The line for compressions grew and I waited for something to feel during each pulse check.

Nothing. She died the day before her birthday.

This was my second code in the Emergency Department and particularly striking, because of how quickly she decompensated. She had ruptured esophageal varices and as anyone who has ever seen these patients knows, it is a true emergency. During the code, I was check ing for a femoral pulse. Because I was there for so long, I found myself looking at her face fre quently and it is one that I don’t think I will forget. This patient made a huge impact on me and the other two medical students I was with that night, and that impact is ever-changing. I think we must never forget that our patients are all people with their own worries, joys, dreams, and loved ones and that all of these things can be taken away in an instant. We must also never forget that these same things apply to us as well – and we should remember to live our lives in the way that brings us the most happiness and joy.

By Amber Warren, Class of 2023

Two Generations Serving BCMS

A Look Back

By John M. Smith III, MD

John M. Smith, Jr. was born in 1914 in Caldwell, the country seat of Burleson County. His mother was part of the Burleson family, a distinguished group of patriots and leaders beginning with the creation of Texas as a republic.

His early childhood was spent in San Anto nio, where he attended Main Avenue High School. He received further education at St. Mary’s University and in Denton the institu tion there to become University of North Texas. He felt privileged to attend the Tulane University School of Medicine, the first med ical school west of the Mississippi. Following medical school, he interned at the Robert B. Green hospital where he was a roommate with Dr. John Hinchey. Both of these gentlemen were to become giants in leadership of their city, state and national organizations both within the medical profession and in civic affairs.

Dr. Smith graduated from Tulane Medical School in 1940 and joined the Army the fol lowing year. He served in his general hospital that established a tent hospital in the sand dunes of Normandy following D-day. They ul timately moved their base operations to Metz, where they occupied a 3,000-bed hospital that had been evacuated by the Germans following their eviction by General Patton. In Metz, they received the majority of casualties of the Battle of the Bulge from both sides of the conflict.

Following V-E Day, Dr. Smith was trans ferred back to the United States where he im mediately asked Jane Jordan from Victoria, Texas; a student at Newcomb when he was at tending medical school to marry him. The two began their married life at Fort Bliss, El Paso, Texas where Dr. Smith was involved in the or thopedic rehabilitation surgery of the soldiers hospitalized there.

After discharge from the Army, considering San Antonio his home, Dr. Smith wanted to practice in San Anto nio. Dr. Witten B. Russ offered him, one of his extra rooms at the M&S Hospital in which he was permit ted to establish his own practice. His practice was begun with one employee and a shingle hanging in the lobby. Dr. Russ was a great in spiration for him, hav ing been the youngest president ever of the Texas Medical Associ ation. Under Dr. Russ’ leadership the initial Texas Medical Practice Act and the State Sys tem for Treatment of Tuberculosis were es tablished. Dr. Russ was no doubt an inspira tion for him to become involved in the medical affairs of San Antonio and the State of Texas.

Upon establishing practice and joining the Bexar County Medical Society (BCMS), Dr. Smith was appointed to head a committee to study the health care needs of the city of San Antonio going forward. His findings were that San Antonio was the largest city in the United States without a medical school, and was the most deficit hospital bed per capita city of half a million in country. A coalition

that included the Chamber of Commerce, the Bexar County Medical Society and other city leaders joined together to form the Bexar County Medical Foundation. The foundation was established in 1947, and the initial object of the foundation was not only to see that a medical school was built in San Antonio, but also to establish a medical center and to im prove quality of medicine overall. At the time, Texas had one medical school located in Galveston. There was a medical school in Dal

las which was encouraged to move to Houston by the efforts of the leaders in Houston, then establishing a medical center and school there. It goes without saying that there was signifi cant political pressure for the State of Texas to create another medical school. Dr. Smith and the medical foundation were involved in this achievement from day one. The effort to create a medical center in San Antonio involved a great deal of effort on the part of city leaders and citizens who understood the necessity and challenge. The political effort to establish a medical school in San Antonio, took a lot of convincing of the various politicians involved. The year that the Texas Legislature passed a bill establishing a new medical school for San Antonio, Dr. John M. Smith, Jr. was voted the most outstanding citizen in San Antonio for his efforts and success in that regard.

One of the pieces of this effort required some group to build a teaching hospital within the medical center. Dr. Smith lobbied the Methodist bishop for them to establish a hos pital within the medical center, along the lines of the Methodist in Houston and Dallas. Re grettably, he was rebuffed by the Methodist bishop at that time. Leadership changed, he encountered another bishop who was more at tuned to supporting the effort of having a Methodist Hospital to anchor the new med ical center in San Antonio. Fortunately, this was accomplished and was part of the success in garnering a medical school for the new medical center.

Further the other piece that was necessary was for a bond issue to pass Bexar County in which a new teaching hospital would be con structed within the medical center. A lot of political effort was expended in this endeavor which is a separate story by itself. Ultimately with the leadership of the county judge, Blair Reeves, this succeeded.

Dr. John M. Smith, Jr. received numerous awards for his efforts in organized medicine. These included the distinguished service awards from the Texas Medical Association, the American Medical Association, and oth

ers. He served in the leadership position of the Bexar County Medical Society as its President and the Texas Medical Association as its Pres ident and Chairman of the Board of Trustees. His leadership position of the San Antonio Medical Foundation guided it as well. His leadership and judgement both within the city, the region, the state and nationally was respected and sought.

During this time, Dr. Smith carried on an ac tive medical practice which was for the most part a solo practice with others substituting when he was out of town. His family practice waiting room included city employees waiting to be seen with various injuries, pregnant women who were anticipating delivering chil dren and families of those who established the banks and major industrial endeavors about the town and region. All were considered as VIPs.

I was a first-hand observer of how hard my father worked and what few leisure hours he actually enjoyed. I was somewhat skeptical of the medical profession pressures. However, after making house calls with him all over Bexar County and observing deliveries and surgical procedures, I became much more in terested in it as a personal career. In that re spect, I was never pushed to pursue medicine, but I was provided the opportunity to see the rewards to the practitioner were from people grateful for the care that they received.

I graduated from Tulane Medical School in 1972. I was enormously proud of the educa

tion and opportunity that I had received there which was broad and diverse to say the least. Charity Hospital in New Orleans provided a glimpse of almost every condition that a human being could experience.

While in my first year at Tulane, Christian Barnard came to speak. He had not long be fore implanted the first human heart and the thought that this could be done encouraged me to pursue the thoughts of becoming a tho racic and cardiovascular surgeon.

My internship was spent in Dallas with Dr. Tom Shires as the Chief of the Department of Surgery. As part of this internship year, I spent three or four months on medical services with the idea of becoming an “adept medical prac titioner” in addition to whatever surgical abil ity I might ultimately acquire. The surgery program in Dallas was indeed an academic one and I was offered a year in the laboratory prior to a beginning a more traditional surgical residency, thinking that I ultimately wanted to pursue another four years of thoracic surgery hesitant to lengthen it further. After general surgery I transferred to the medical school in San Antonio where Dr. Aust offered me a tra ditional four-year surgical residency. It should be noted that Dr. Aust held the Witten B. Russ Chair of Surgery, one endowed by Dr. Russ’ brother. During those four years of sur gery residency, I was privileged to spend 18 months in total with Dr. Kent Trinkle, a gifted

and inspiring thoracic surgeon. Dr. Trinkle had established a rotation with Dr. Denton Cooley to expose the San Antonio residents to the truly world-wide practice that Dr. Coo ley enjoyed. While working under Dr. Coo ley’s tutelage, I was offered a residency in the fall of the coming year at the Texas Heart In stitute, which I gladly accepted. This was an exceptional opportunity for me as it exposed me to a world of cardiovascular surgery in both adults and children as perhaps no other program would have under the mentorship of one of the world’s truly great heart surgeons.

When I reflect on the medical profession beginning with my father’s graduation from medical school in 1940 up to the present, it is indeed an interesting history. Despite the number of distinguished medical families in Bexar County and the number of people who are truly visionaries in their fields, it is the case that my father and I are the only father-son who have served as presidents of the Bexar County Medical Society. As a leader for the profession and for public health, the Bexar County Medical Society has accomplished many achievements both locally and on a statewide basis. This type of participation is es sential to preserve the future of medicine.

Following my rotation with Dr. Cooley, I entered the United States Air Force to serve at the Wilford Hall US Air Force Medical Cen ter. This was the one location that the Air Force did heart surgery at the time I entered active duty. We received patients from literally all over the world and my experience in serving my country was a definite bright spot in my career. At the end of my service at Wilford Hall, I was the Acting Chief of the Depart ment of Thoracic and Cardiovascular Surgery and received the Air Force commendation medal for my service in that capacity.

Medicine is a profession. The meaning of the word is that the practitioner places the in terest of the patient above his own. I fear that medicine as it has moved away from individual practices and to employed practitioners of the

present day, some of that sense of responsibil ity and service may have been lost. I fear that too many present-day graduates are seeking employment first and foremost which may re sult in the bending of their view concerning the profession and service to their communi ties. As the institutions have become increas ingly taken over by commercial entities as opposed to educational and benevolent organ izations, I see that the pressure placed on the practitioner is heavily weighted towards eco nomic or production goals versus that which the practitioners think is best for their pa tients. The individuals in these various organ izations must be vigilant in protecting the best interest of those whom they serve and the communities in which they live.

Great privileges are afforded to doctors and the medical profession which are based on the belief from the public that their interests are being placed first and foremost. Should it ever be the case that the public sees that their in terests are being subjugated to commercial benefit, that respected appreciation for med ical practitioners will evaporate.

I observed first hand many of the civic pur suits my father pursued. At a young age I was impressed that it was incumbent upon the doctor to be part of the development of his community, his professional organizations, and the profession. I personally witnessed the groundbreaking for the Methodist Hospital in the San Antonio medical center and as a citi zen of San Antonio have taken great pride in seeing the progress of our medical school and medical center. My public service included the first resident delegate to the American Med ical Association, eight years on the Board of Managers of the Bexar County Medical Soci ety, eight years on the Standards and Ethics Committee of the STS and serving on the Board of the Methodist Hospital Foundation.

The governance of Methodist Hospital which initially was directed first and foremost by its medical staff. As the staff has increas ingly been employed by the hospital corpora

tion, the governance of the hospital has been increasingly influenced by economic motiva tions rather than quality issues. This is mani fested in the evidence of the hospital placing less interest in rewarding the nursing staff to maintain its satisfaction. This is evidenced by less tenure and experience in the medical staff.

Some 60 doctors became involved in the creation of Texsan Heart Hospital for the pur pose of providing excellence in cardiovascular care. The hospital did indeed achieve its pur poses. The Affordable Care Act made doctor ownership in hospitals untenable going for ward and Texsan was subsequently purchased by Methodist. In my opinion, this resulted in diminished tenure and ability of those work ing within the hospital.

The challenges for the profession going for ward are many. I learned a number of lessons from the examples set for me by my father and his service to the community and the profes sion. I am hopeful that through some set of circumstances this can be conveyed to the next generation of professionals who will assume the mantle of leadership in medicine.

Texas State Historical Association, Smith, John Marvin, Jr. (1914-2003) by William V. Scott Marquis Who’s Who Top Doctors, 2022

J. Marvin Smith III, MD has been a cardiothoracic surgeon in San Antonio since his honorable discharge from the Air Force in 1982. He has received numerous awards and appointments within and outside the medical community. He holds certifications by the Amer ican Board of Surgery and the American Board of Thoracic Surgery, is a fellow of the American College of Surgeons and a fellow of the American College Cardiology. Dr. Smith is an Adjunct Professor of Surgery in the Department of Cardiothoracic Surgery at University of Texas Health Science Center at San Antonio and a member of the Bexar County Medical Society.

“To See Ourselves

The Works of Dr. Oliver Sacks

By David Schulz

Oeuvre is a word not used casually outside the works of a Dickens or a Doyle, and rarely does the effort of a brilliant scientist find ex pression in sufficient numbers of volumes, but for Oliver Sacks, MD, his manifold writings on neurological issues in lay terminology earned him the title “The Poet Laureate of Medicine” by The New York Times. From Awakenings (1973) to Gratitude (2015), Dr. Sacks’ legacy explores the vagaries of the human mind, documenting and spurring ad vances in the study of brain and thought over a half-century in practice.

Awakenings describes his work in the 1960s at Beth Abraham Hospital in the Bronx, where he found a population of immobile adult patients, speechless and apparently de pressed. Working back, he found their com monality was contracting a sleeping sickness, encephalitis lethargica, during an epidemic forty years prior. His novel approach to treat ing them with levodopa (L-dopa), then only recently applied to Parkinsonism, unlocked his patients, and for a brief period, returned them to a state of full self-consciousness. Un fortunately, side effects became as debilitating as the disease. Their story was so compelling that the film version, which starred Robert De Niro and Robin Williams, was nominated for three Academy Awards in 1991, including best picture.

Dr. Sacks’ curiosity about perception, selfperception, and experiential perception were explored in more than a dozen works. He in vestigated the world of deaf people and sign language in Seeing Voices, a rare community of colorblind people in The Island of the Color blind, and examined the visual brain in his books The Mind’s Eye and Hallucinations. He explored the many manifestations of mi

graines in Migraine, wrote about an unfortunate accident involving a bull in A Leg to Stand On, and published a spellbinding account of his trip to Mexico with a group of fern enthusiasts in Oaxaca Journal

The Man Who Mistook

His Wife for a Hat is a com pendium of people afflicted with fantastic perceptual and intellec tual aberrations, studies of life struggling against incredible adversity.

In Musicophilia, he examines the powers of music through the individual experiences of patients, musicians, and everyday people–from a man who is struck by lightning and suddenly inspired to become a pianist at the age of forty-two, to an entire group of chil dren with Williams syndrome who are hyper musical from birth; from people with “amusia,” to whom a symphony sounds like the clattering of pots and pans, to a man whose memory spans only seven seconds–for everything but music.

From beginning of his career to its end, the compassionate tales of people struggling to adapt to different neurological conditions have fundamentally changed the way we think of our own brains, and of the human experi ence. Just as his first book describes the return to functioning life, albeit briefly, of his earliest patients, the last work, Gratitude, deals with aging, illness and death, with he himself as the subject: “I am now face to face with dying, but I am not finished with living,” he prefaces.

Knowing the terminal nature of his cancer, first occurring in the eye (leaving him blind in one), then metastasizing in the liver, he wrote, “Over the last few days, I have been able to see my life as from a great altitude, as a sort of

landscape, and with a deepening sense of the connection of all its parts. This does not mean I am finished with life.… I feel a sudden clear focus and perspective. There is no time for anything inessential. I must focus on myself, my work, and my friends. I shall no longer look at the NewsHour every night. I shall no longer pay any attention to politics or argu ments about global warming.”

In essays published following his passing in 2015 (The River of Consciousness), Dr. Sacks is revealed to be as perceptive a student of sci ence history as he is a scientist. His writing on Darwin and the meaning of flowers puts his theories of evolution and origin of species into clear, concise prose: “Here, in no uncertain terms, Darwin is throwing down the gauntlet, saying, “Explain that better—if you can.”

Tribute to Dr. Sacks was suggested by a reader, and all of Dr. Sacks’ books are available in print, e-edition and audio from San Antonio Public Library. Please don’t hesitate to let us know if there’s an author of which you believe our readership ought to be aware.

David Alex Schulz, CHP is a com munity member of the BCMS Publi cations Committee.

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“More Than Just Your Advisor, We're Your Wealth Management Partner”

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We learn your individual needs so we can develop a strategy to help you achieve your financial goals.

Join the nearly 7 million investors who know. Contact me to develop an investment strategy that makes sense for you.

Elizabeth Olney, Financial Advisor 210-858-5880

Elizabeth.olney@edwardjones.com www.edwardjones.com/elizabeth-olney "Making Sense of Investing"

HOSPITALS/ HEALTHCARE

FACILITIES

sional reporting that helps you accommodate further growth and drive your practice forward.

Rana Camargo

Senior Account Manager 210-771-7903

Bertuzzi-Torres Wealth Management Group (

Gold Sponsor)

We specialize in simplifying your personal and professional life. We are dedicated wealth managers who offer diverse financial solu tions for discerning healthcare professionals, including asset pro tection, lending & estate planning.

Mike Bertuzzi

First Vice President Senior Financial Advisor 210-278-3828

Michael_bertuzzi@ml.com

Ruth Torres Financial Advisor 210-278-3828 Ruth.torres@ml.com http://fa.ml.com/bertuzzi-torres

Nexus Neurorecovery Center

(HHH Gold Sponsor)

A post-acute rehabilitation facility focusing on brain injuries. Pro gramming provides individual and group physical, occupational, cog nitive, and speech therapy. We help residents return to lives of productivity and meaning.

Sydney Kerr Liaison 346-339-2654 skerr@nhsltd.com

Caitlyn Tewksbury

ctewksbury@nhsltd.com

Justin Sanderson CEO 210-854-4732 jsanderson@nhsltd.com

Nexus Neurorecovery Center

227 Lewis St, San Antonio, TX 78212

https://nexushealthsystems.com

ranac@expressinfo.com www.expressinfo.com

“Leaders in Healthcare Software & Consulting”

INSURANCE

INSURANCE/MEDICAL MALPRACTICE

Aspect Wealth Management (HHH Gold Sponsor)

We believe wealth is more than money, which is why we improve and simplify the lives of our clients, granting them greater satisfaction, confidence and freedom to achieve more in life.

Michael Clark, President 210-268-1520 mclark@aspectwealth.com www.aspectwealth.com

“Get what you deserve … maximize your Social Security benefit!”

HEALTHCARE BANKING

Amegy Bank of Texas (HH Silver Sponsor)

We believe that any great relationship starts with five core values: Attention, Accountability, Appreciation, Adaptability and Attainability. We work hard and together with our clients to accomplish great things.

Jeanne Bennett

EVP | Private Banking Manager 210-343-4556

Jeanne.bennett@amegybank.com

Karen Leckie

Senior Vice President | Private Banking 210-343-4558

karen.leckie@amegybank.com

Robert Lindley

Senior Vice President | Private Banking 210-343-4526

robert.lindley@amegybank.com

Denise C. Smith

Vice President | Private Banking 210-343-4502

Denise.C.Smith@amegybank.com www.amegybank.com

“Community banking partnership”

“To return patients to lives of pro ductivity and meaning”

TMA Insurance Trust (HHHH 10K Platinum Sponsor)

TMA Insurance Trust is a full-service insurance agency offering a full line of products – some with exclusive member discounts and staffed by professional advisors with years of experience. Call today for a compli mentary insurance review. It will be our privilege to serve you.

Wendell England Director of Member Benefits 512-370-1776 wendell.england@tmait.org 800-880-8181 www.tmait.org

“We offer BCMS members a free insurance portfolio review.”

Texas Medical Liability Trust (HHHH 10K Platinum Sponsor)

With more than 20,000 health care professionals in its care, Texas Medical Liability Trust (TMLT) pro vides malpractice insurance and related products to physicians. Our purpose is to make a positive im pact on the quality of health care for patients by educating, protect ing, and defending physicians.

Patty Spann 512-425-5932 patty-spann@tmlt.org www.tmlt.org

Recommended partner of the Bexar County Medical Society

UT Health San Antonio MD Anderson Cancer Center, (HHH Gold Sponsor)

UT Health San Antonio MD Ander son Cancer Center, is the only NCI-designated Cancer Center in South Texas. Our physicians and scientists are dedicated to finding better ways to prevent, diagnose and treat cancer through lifechanging discoveries that lead to more treatment options.

Laura Kouba, Manager, Physician Relations 210-265-7662

NorrisKouba@uthscsa.edu

Lauren Smith, Manager, Marketing & Communications 210-450-0026

SmithL9@uthscsa.edu Cancer.uthscsa.edu

Appointments: 210-450-1000

UT Health San Antonio MD An derson Cancer Center 7979 Wurzbach Road San Antonio, TX 78229

INFORMATION AND TECHNOLOGIES

Guardian (★★★ Gold Sponsor)

Live Confidently. Every financial dream deserves a well-crafted plan.

Ned Hodge 210-332-3757 ned@nedhodge.com www.nedhodge.com | www.Opesone.com

“Take care of today then plan for tomorrow”

The Bank of San Antonio Insurance Group, Inc. (HHH Gold Sponsor)

We specialize in insurance and banking products for physician groups and individual physicians. Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insur ance for the medical community.

Katy Brooks, CIC 210-807-5593 katy.brooks@bosainsurance.com www.thebankofsa.com “Serving the medical community.”

MedPro Group

(HH Silver Sponsor)

Rated A++ by A.M. Best, MedPro Group has been offering customized insurance, claims and risk solutions to the healthcare community since 1899. Visit MedPro to learn more.

Kirsten Baze 512-658-0262 Kirsten.Baze@medpro.com www.medpro.com

Humana (HHH Gold Sponsor)

Humana is a leading health and well-being company focused on making it easy for people to achieve their best health with clinical excellence through coordinated care.

Jon Buss: 512-338-6167

Jbuss1@humana.com

Express Information Systems

(HHH Gold Sponsor)

With over 29 years’ experience, we understand that real-time visi bility into your financial data is critical. Our browser-based healthcare accounting solutions provide accurate, multi-dimen

Shamayne Kotfas: 512-338-6103 skotfas@humana.com www.humana.com

ProAssurance

(HH Silver Sponsor)

ProAssurance professional liability insurance defends healthcare providers facing malpractice claims and provides fair treatment for our insureds. ProAssurance Group’s rating is AM Best A (Excellent).

Mike Rosenthal

Senior Vice President, Business Development 800-282-6242

MikeRosenthal@ProAssurance.com www.ProAssurance.com

INVESTMENT ADVISORY REAL ESTATE

PURCHASING DIRECTORY

Alexandria.n.thomas12.mil@army. mil https://recruiting.army.mil/mrb/ “Service to Country, Army Medi cine, Experientia et Progressus”

Alamo Capital Advisors LLC (★★★★ 10K Platinum Sponsor)

Focused on sourcing, capitalizing, and executing investment and de velopment opportunities for our in vestment partners and providing thoughtful solutions to our advisory clients. Current projects include new developments, acquisitions & sales, lease representation and fi nancial restructuring (equity, debt, and partnership updates).

Jon Wiegand, Principal 210-241-2036 jw@alamocapitaladvisors.com www.alamocapitaladvisors.com

MEDICAL BILLING AND COLLECTIONS SERVICES

Commercial & Medical Credit Services (HH Silver Sponsor)

A bonded and fully insured San Antonio-based collection agency. Henry Miranda 210-340-9515 hcmiranda@sbcglobal.net www.cmcs-sa.com

“Make us the solution for your account receivables.”

MOLECULAR DIAGNOSTICS LABORATORY

REAL ESTATE SERVICES COMMERCIAL

BCMS. In addition to traditional staffing solutions, Favorite offers a comprehensive range of staffing services to help members improve cost control, increase efficiency and protect their revenue cycle.

Alamo Capital Advisors LLC

(★★★★ 10K Platinum Sponsor)

Cindy M. Vidrine

MEDICAL SUPPLIES AND EQUIPMENT

Henry Schein Medical (HH Silver Sponsor)

From alcohol pads and bandages to EKGs and ultrasounds, we are the largest worldwide distributor of medical supplies, equipment, vaccines and pharmaceuticals serving office-based practitioners in 20 countries. Recognized as one of the world’s most ethical companies by Ethisphere.

Tom Rosol 210-413-8079 tom.rosol@henryschein.com www.henryschein.com

“BCMS members receive GPO discounts of 15 to 50 percent.”

iGenomeDx ( Gold Sponsor)

Most trusted molecular testing laboratory in San Antonio provid ing FAST, ACCURATE and COM PREHENSIVE precision diagnostics for Genetics and Infectious Diseases.

Dr. Niti Vanee Co-founder & CEO 210-257-6973 nvanee@iGenomeDx.com

Dr. Pramod Mishra Co-founder, COO & CSO 210-381-3829 pmishra@iGenomeDx.com www.iGenomeDx.com

“My DNA My Medicine, Pharma cogenomics”

PROFESSIONAL ORGANIZATIONS

The Health Cell (HH Silver Sponsor)

“Our Focus is People” Our mis sion is to support the people who propel the healthcare and bio science industry in San Antonio. Industry, academia, military, nonprofit, R&D, healthcare delivery, professional services and more!

Kevin Barber, President 210-308-7907 (Direct) kbarber@bdo.com

Valerie Rogler, Program Coordinator 210-904-5404

Valerie@thehealthcell.org www.thehealthcell.org

“Where San Antonio’s Healthcare Leaders Meet”

San Antonio Medical Group Man agement Association (SAMGMA) (HH Silver Sponsor)

Focused on sourcing, capitalizing, and executing investment and de velopment opportunities for our in vestment partners and providing thoughtful solutions to our advisory clients. Current projects include new developments, acquisitions & sales, lease representation and fi nancial restructuring (equity, debt, and partnership updates).

Jon Wiegand, Principal 210-241-2036

jw@alamocapitaladvisors.com www.alamocapitaladvisors.com

CARR Realty

(HH Silver Sponsor)

CARR is a leading provider of commercial real estate for tenants and buyers. Our team of health care real estate experts assist with start-ups, renewals, reloca tions, additional offices, pur chases and practice transitions.

Brad Wilson Agent 210-573-6146 Brad.Wilson@carr.us www.carr.us

“Maximize Your Profitability Through Real Estate”

RETIREMENT PLANNING

Director of Operations- Texas 210-918-8737

cvidrine@favoritestaffing.com

“Favorite Healthcare Staffing offers preferred pricing for BCMS members.”

San Antonio Army Medical Recruiting office (HH Silver Sponsor)

Mission: Recruit highly qualified and motivated healthcare professionals for service in the Army Reserves or Active Duty Army, in support of Sol diers and their families.

1LT Thomas Alexandria 210-328-9022

Alexandria.n.thomas12.mil@army.mil https://recruiting.army.mil/mrb/

“Service to Country, Army Medicine, Experientia et Progressus”

MILITARY

San Antonio Army Medical Recruiting office (★★Silver Sponsor)

Mission: Recruit highly qualified and motivated healthcare profes sionals for service in the Army Reserves or Active Duty Army, in support of Soldiers and their families.

1LT Thomas Alexandria 210-328-9022

SAMGMA is a professional nonprofit association with a mission to provide educational programs and networking opportunities to medical practice managers and support charitable fundraising.

Alan Winkler, President info4@samgma.org www.samgma.org

Oakwell Private Wealth Management (HHHH 10K Platinum Sponsor)

Oakwell Private Wealth Manage ment is an independent financial advisory firm with a proven track record of providing tailored finan cial planning and wealth manage ment services to those within the medical community.

Brian T. Boswell, CFP®, QKA Senior Private Wealth Advisor 512-649-8113

SERVICE@OAKWELLPWM.COM www.oakwellpwm.com

“More Than Just Your Advisor, We're Your Wealth Management Partner”

STAFFING SERVICES

Favorite Healthcare Staffing

(HHHH 10K Platinum Sponsor)

Serving the Texas healthcare commu nity since 1981, Favorite Healthcare Staffing is proud to be the exclusive provider of staffing services for the

2022 Ford Maverick

By Stephen Schutz, MD

In January of this year, Ford stopped taking orders for its new com pact Maverick pickup truck because it had become too popular. Amaz ing but true.

They’re taking orders now, but expect to wait up to six months if you order one today unless you get lucky and find an unsold one on a dealer’s lot (expect to pay over MSRP by the way).

The Maverick’s popularity shouldn’t surprise anyone. In these pickup-crazy times the compact Maverick pickup provides seating for five, a small but decent size bed and good fuel efficiency. That last part is extra welcome as we all struggle with inflation and high gasoline prices.

And having the same name as a certain Navy aviator played by Tom Cruise in the box office smash Top Gun can’t hurt.

Design-wise the four-door Maverick doesn’t break any new ground, but most pickups don’t. The styling is boxy with hints of its showroom siblings the Ford Bronco Sport and F-150, and maybe, a touch of Honda Ridgeline (interestingly but not surprisingly the Maverick looks almost nothing like its slower selling mid-size brother the Ranger). Anyway, it looks good.

The Maverick is more capable than you might think with plenty of space for stuff and a 4,000 lbs. towing capacity. The bed is small, as noted above, but most DIY-ers will find it big enough for whatever they need from Lowes or Home Depot, and Costco runs will be no sweat.

There are many people driving (thirsty) full-size pickup trucks today who would do just fine with a Maverick. If you regularly haul drywall or tow a big boat then you’re better off with an F-150 or Chevy Sil verado, but otherwise Ford’s smallest pickup is a good choice.

Typically, pickup powertrains are easy to describe—a couple of en gine choices with RWD vs 4WD is generally it—but that’s not the case with the Maverick. The standard setup is a hybrid 2.5L four-cylin der with e-assist good for 191HP, although FWD and the dreaded continuously variable transmission (CVT) are the only way to get the base powertrain. Optional is a non-hybrid 250HP turbocharged 2.0L four-cylinder engine mated to a (much better) 8-speed automatic transmission. The turbo can be configured with either FWD or AWD, and that along with AWD would be my choice (the turbo FWD truck is a reasonable alternative because it avoids the CVT).

All Mavericks get excellent fuel economy. Hybrid models get 42MPG City and 33MPG Highway, non-hybrids with FWD get 23MPG and 30MPG respectively, and AWD non-hybrids are 22MPG/29MPG. Those are all impressive numbers, and they easily

best those of any mid- or full-size pickup on the market.

Driving the Maverick is very pleasant, especially around town and on B-roads. It’s not sporty by any means, but it at least handles, unlike full-size pickups, and, of course, it’s much easier to park than any big truck.

Naturally, interstate driving is significantly more enjoyable in a fullsize pickup than a Maverick. I’ve gone on record before stating that the Ford F-150 is just about the best interstate vehicle you can buy, and I think that’s still true.

Mavericks are available in three trims, XL, XLT and Lariat. XL Mavericks lack many creature comforts that most buyers today expect, but it could make for a good commuter vehicle/occasional hauler. Springing for the XLT adds 17-inch aluminum wheels, cruise control, a power lock for the tailgate, power exterior mirrors and more, which predictably results in it being the most popular model. As noted above, I'd select the optional turbocharged 2.0-liter four-cylinder for its su perior acceleration and drivability. To get the Maverick's maximum towing capacity of 4,000 pounds, I'd also order the Tow package.

A new Tremor Off-Road package will be available for 2023 models. The Tremor option includes more rugged exterior styling elements as well as off-roading enhancements, and it can be added to either XLT or Lariat Mavericks. Only non-hybrid AWD models can be had with the Tremor package.

In an era when the average MSRP of new cars approaches $50,000, the Maverick’s pricing is a bright spot: a stripped version stickers for around $23,000, and a loaded Lariat Tremor lists for under $35,000.

Spoiler alert: it’s doubtful that anyone can pay sticker for a Maverick right now, so it’s extra important that you buy through Phil Hornbeak at BCMS to get your best deal.

The Ford Maverick compact pickup truck is very popular, and after driving one for a week I can see why. It provides a lot of the utility of a full-size pickup, easier parking and much better fuel economy. I ex pect it to sell for over sticker and be hard to get for quite some time.

As always, call Phil Hornbeak, the Auto Program Manager at BCMS (210-301-4367), for your best deal on any new car or truck brand. Phil can also connect you to preferred financing and lease rates.

Stephen Schutz, MD, is a board-certified gastroenterologist who lived in San Antonio in the 1990s when he was stationed here in the US Air Force. He has been writing auto reviews for San Antonio Medicine since 1995.

11911 IH 10 West San Antonio, TX 78230

Coby Allen 210-696-2232

Kahlig Auto Group

Bluebonnet Chrysler Dodge Ram 547 S. Seguin Ave. New Braunfels, TX 78130

Matthew C. Fraser 830-606-3463

Audi Dominion 21105 West IH 10 San Antonio, TX 78257

Rick Cavender 210-681-3399

Land Rover San Antonio 13660 IH 10 West San Antonio, TX

Cameron Tang 210-561-4900

Kahlig Auto Group

Northside Ford 12300 San Pedro San Antonio, TX

Marty Martinez 210-477-3472

Kahlig Auto Group

Northside Chevrolet

9400 San Pedro Ave. San Antonio, TX 78216

Charles Williams 210-912-5087

Chuck Nash Chevrolet Buick GMC 3209 North Interstate 35 San Marcos, TX

William Boyd 210-859-2719

North Park Mazda 9333 San Pedro San Antonio, TX 78216

John Kahlig 210-253-3300

Kahlig Auto Group

North Park Lexus 611 Lockhill Selma San Antonio, TX

Tripp Bridges 210-308-8900

Northside Honda 9100 San Pedro Ave. San Antonio, TX 78216

Paul Hopkins 210-988-9644

Kahlig Auto Group

North Park Lexus at Dominion 25131 IH 10 W Dominion San Antonio, TX

James Cole 210-816-6000

14610 IH 10 West San Marcos, TX 78249

Mark Hennigan 832-428-9507

Kahlig Auto Group

North Park Subaru 9807 San Pedro San Antonio, TX 78216

Raymond Rangel 210-308-0200

Mercedes Benz of Boerne 31445 IH 10 West Boerne, TX

James Godkin 830-981-6000

Kahlig Auto Group

North Park Subaru at Dominion 21415 IH 10 West San Antonio, TX 78257

Phil Larson 877-356-0476

Mercedes Benz of San Antonio 9600 San Pedro San Antonio, TX

Al Cavazos Jr. 210-366-9600

North Park Lincoln 9207 San Pedro San Antonio, TX

Sandy Small 210-341-8841

Cavender Toyota 5730 NW Loop 410 San Antonio, TX

Gary Holdgraf 210-862-9769

9455 IH 10 West San Antonio, TX 78230

Douglas Cox 210-764-6945

Kahlig Auto Group

North Park Toyota 10703 Southwest Loop 410 San Antonio, TX 78211

Justin Boone 210-635-5000